TREATMENTS - DIABETES

Diabetes Mellitus - About one in five people with diabetes will enter the hospital for foot problems.

DIABETIC FOOT PROBLEMS
by Robert Frykberg, DPM

Foot problems are leading causes of hospitalization for the 16 million persons in the United States with diabetes mellitus accounting for expenditures of hundreds of millions of dollars annually. It has been estimated that 15% of all diabetics will develop a serious foot problem at some time, which can potentially threaten their limb or even their life. The most common of these problems are infection, ulceration, or gangrene (death of the tissue) which can lead , in the most severe of cases, to amputaton of a toe, foot, or leg.

The good news is that most of these problems can be prevented through regular podiatric visits, patient education, daily foot inspection and care, proper footwear, and early recognition and treatment of any suspected trouble areas. This can only be accomplished with active participation in your own care along with the help and guidance of your foot specialist.

People with diabetes can develop a variety of foot problems. Even ordinary problems can quickly get worse and lead to serious complications. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor. Inspect your feet every day, and seek care early if you do get a foot injury. Make sure your health care provider checks your feet at least once a year-more often if you have foot problems. Your health care provider should also give you a list and explain the do's and don'ts of foot care. (See below)

What Causes Foot Problems in Diabetes?
It is well established that the longer a person has the disease, the greater is the incidence and severity of complications of diabetes mellitus. Although good control of blood sugar and blood pressure are extremely important in maintaining your optimum health, other factors can be important in the development of diabetic foot disorders.

Foot problems in persons with diabetes are usually the result of three primary factors :

Neuropathy (diminished sensation), Poor circulation, and a decreased resistance to Infection. Additionally, Foot deformities and Trauma play major roles in causing ulcerations and infections in the presence of neuropathy or poor circulation.

Neuropathy can generally be defined as a loss of sensation or alteration in sensitivity in the feet and legs. There may be a diminished or absent ability to detect painful sensations such as a pinprick or the heat of sand at the beach in the Summer or hot water. Your ability to detect the tightness of a shoe might also be affected. Neuropathy can prevent the recognition of injuries to the feet and permit them to remain untreated for lengthy periods of time. Continued walking on the injured or infected foot results in further trauma and injury.

Sometimes neuropathy can be painful and quite distressing, especially at night when you are trying to sleep. Painful neuropathy usually causes burning or sharp shooting pains in the feet. It is even possible for some people to have painful neuropathy in combination with an actual loss of external sensation as described above.

Neuropathy can also cause muscle weakness in the legs and feet. This might give rise to such conditions as "foot drop", where the foot cannot be raised at the ankle when walking. Other common deformities associated with this might be hammertoes or bunions; these are often also associated with corns or calluses.

Poor Circulation
People with diabetes often have varying degrees of circulation disorders to their legs and feet due to atherosclerosis and blockage of arteries. Common symptoms of peripheral vascular disease are cramping in the calf or buttocks when walking. Temperature and color changes in the feet, in addition to loss of hair and thickening of toenails, might also be attributed to circulatory changes.

Poor circulation results in reduced blood flow to the feet. Adequate delivery of oxygen and nutrients, which are required for normal maintenance and repair, is then restricted. This becomes critical when the foot is injured, infected, or ulcerated, since healing will be impaired or will not occur at all. Long a major cause of lower extremity amputation, peripheral vascular disease can now be frequently corrected by vascular bypass operations in the legs. This is similar to those operations performed in the heart for blocked arteries.

Infection
Infections are often a problem in persons with diabetes, since they have difficulty fighting off bacteria that enter the skin from cuts or other wounds. This is due, in part, to certain deficiencies in the activity of white blood cells. Apparently, uncontrolled high glucose levels impair normal immune responses to bacterial invaders. The result can be an overwhelming infection in the foot.

Without the ability to feel pain or without the ability to deliver white blood cells to the site of injury, infections can frequently become serious in a short period of time. The first sign of such serious infections might be very high blood sugars or flu-like symptoms, which I call the "Diabetic Foot Flu". Unfortunately, fever is often absent or delayed in diabetic foot infections. Therefore, when you develop a fever, proper attention must be given to your situation immediately. Infections are the most frequent reason for hospitalizing diabetic patients and can progress to bone involvement in a relatively short period of time. Deep infections almost always require some type of surgery for treatment, so it is best to catch these problems early and avoid this serious complication.

Foot deformities such as hammertoes, bunions, and metatarsal disorders are common in the general population, but have a special significance in the diabetic population. When neuropathy or poor circulation is present, these deformities place the foot at increased risk for developing pressure lesions (corns, calluses, blisters, ulcerations, etc.) from tight shoes or simple walking. Serious infections can result if these lesions go untreated.

Special deformities can occur in persons with neuropathy and very good circulation. A Charcot joint, resulting from trauma to the insensitive foot, causes the foot to collapse and widen. This very destructive condition is often first heralded by persistent swelling and redness, increased warmth in the affected foot, some mild to moderate aching, and an inability to fit into your usual shoes. If this should occur it is extremely important to stay off your foot and immediately see your podiatric physician. Neglect of this complication can lead to continued collapse of the foot, progressive deformity, and subsequent ulceration.

What is an ulceration and how can it be treated?
An ulceration or ulcer is usually a painless sore on the bottom of the foot or top of toes which results from excessive pressure at that site. Trauma in the form of heat, cold, shoe pressure, or penetration by a sharp object must all be suspected as potential causes. The trauma or injury that causes most of the problems for diabetics' feet doesn't happen all at once, like the injuries that we are most familiar with. Instead, they happen from repeated small injuries, happening over long periods of time; what doctors call "repetitive microinjuries".

Ulcers frequently may form under a pre-existing corn or callus which was permitted to build up too thickly. Neuropathy allows these lesions to develop because the normal warning sense of pain has been lost and they go unrecognized. This would be called a Neuropathic ulcer. Continued pressure or walking on the injured skin creates even further damage and the ulcer will worsen. The open sore will frequently become infected and may even penetrate to bone. Poor circulation can also be a predisposing factor for ulcerations, since the skin is often unable to heal minor cuts or blisters. Instead of healing normally, these minor irritations can also worsen into full thickness ulcers in the skin. Ischemic ulcers, as these might be called, are usually quite painful, unless neuropathy is also present at the same time. In the latter instance, such ominous lesions would be called Neuro-ischemic ulcers.

Treatment relies heavily on early recognition of the ulceration, avoidance of weight bearing (walking), and early intervention by your foot doctor. Debridement, or trimming away callus and dead tissue, is an essential part of ulcer treatment. In fact, frequent debridement has been shown to lead to higher rates of healing than when such frequent care was not given. Recently, new agents such as topical growth factors or tissue replacements have become available, which can also speed the rate of wound healing when blood supply and good wound care is practiced. Aside from local wound care, dressings, and antibiotics, a variety of other measures may be necessary to adequately relieve pressure from the area. When crutches, wheelchair, or bedrest are not feasible, plaster casts, braces, healing sandals, special shoe inserts or padding may be used to protect the foot while it heals. If circulation is inadequate to allow healing, your podiatrist may recommend that you consult a vascular surgeon for appropriate evaluation and possible vascular reconstructive surgery. Multidisciplinary management is more the rule than the exception for diabetic foot ulcers, because no one specialist can adequately treat all aspects of the disease and its complications. Other health professionals on the team usually include your internist or endocrinologist, cardiologist, orthopedist, neurologist, nurse, diabetes educator, therapist, and pedorthist.

Once your wound is healed, it is extremely important to see your foot doctor regularly for check ups and foot care. Special footwear and inserts will be recommended to protect your feet and prevent new or recurrent lesions from developing.

Foot Surgery in the Diabetic Patient
Realizing the potential danger of foot deformities in the diabetic patient, corrective foot surgery is an option when you are in generally good health and have good circulation. Most deformities progressively worsen over time, as do the effects of neuropathy and vascular disease. Therefore, if such foot deformities cannot be effectively managed with conservative care (orthoses, footwear, and podiatric care) corrective surgery may be indicated.
Podiatric surgery can often be performed as an outpatient under local anesthesia, to minimize potential complications. Your foot surgeon will properly evaluate your situation and coordinate your care with your medical doctor, to ensure that conditions are optimum before undertaking such surgery. In certain circumstances, such as in the presence of an active ulceration, hospitalization may be necessary to properly monitor your postoperative progress. In fact, surgery may be required to heal an ulceration or to eradicate some infections- especially those involving the bone.

Patient compliance is essential for satisfactory outcomes. You must take part in both the decision making and your care, to effectively achieve the goal of a healed, ulcer free foot. Once healed, you must vigilantly guard against injury and provide the daily care necessary to maintain your feet in a healthy status.

Footwear Guidelines
Shoes are meant to protect your feet, not to hurt them. Therefore, shoes must always fit comfortably, with adequate width and depth for the toes. If a shoe is hard to put on, then don't wear it. It is most likely too small for your foot and can cause serious damage, especially if you have neuropathy or poor circulation. Shoes should preferably be made of leather, which will easily adapt to the shape of your feet over time, as well as allow your feet to "breathe". Athletic shoes, jogging shoes, and sneakers are usually an excellent choice, as long as they are well fitted and provide adequate cushioning. In some cases, your podiatrist may recommend "extra depth" shoes or custom molded shoes to accommodate unusually shaped or difficult to fit feet. Also, special insoles or custom orthoses may be prescribed, to provide cushioning and support.

Always check your shoes for foreign objects or torn linings before putting them on. Each day you should wear two or three pair of shoes, so that one pair is not worn for more than four to six hours. New shoes should be worn only for a few hours at a time, taking care to inspect your feet for any points of irritation. Socks should be well fitted without seams or folds and should not be so tight that your circulation is stopped. Well padded socks can be very protective, as long as there is adequate room in your shoes for them.

Above all else, do not walk barefooted . Avoid wearing open - toed shoes or sandals until you have discussed this with your foot doctor. At the beach or pool, however, these might be acceptable, as well as neoprene "aquatic shoes".

Footcare Guidelines
Inspect your feet daily for blisters, bleeding, and lesions between toes. Use a mirror to see the bottom of the foot and heel.

Do not soak your feet. Avoid temperature extremes - don't use hot water bottles or heating pads on your feet.

Wash daily with warm , soapy water and be sure to dry them well, especially between the toes.

Use a moisturizing cream or lotion daily, but avoid between the toes. Do not use acids or chemical corn removers.

Do not perform "bathroom surgery" on corns, calluses, or ingrown toenails. Trim your toenails straight across and file them gently. Have a foot doctor treat you regularly if you cannot trim them yourself without difficulty. Call your foot doctor immediately if your foot becomes swollen, red or painful. Stay off your foot until you see your doctor. Don't smoke.
Learn all you can about your diabetes and how it can affect your feet. Have regular foot examinations by your foot doctor and be sure to remove both shoes and stockings at each visit with any doctor.

AN OVERVIEW OF THE EFFECT ON DIABETES ON YOUR FEET
From The American Diabetes Association

Skin Changes
Diabetes can cause changes in the skin of your foot. At times your foot may become very dry. The skin may peel and crack. The problem is that the nerves that control sweating in your foot no longer work.

After bathing, dry your feet, and seal in the moisture that remains with a thin coat of a lubricant. You can use plain petroleum jelly, unscented hand creams, or other such products.

Do not put oils or creams between your toes. The extra moisture can lead to infection. Also, most health care providers believe you should not soak your feet.

Calluses
Calluses occur more often and build up faster on the feet of people with diabetes. Using a pumice stone every day will help keep calluses under control. It is best to use the pumice stone on wet skin. Put on lotion right after you use the pumice stone.
Calluses, if not trimmed, get very thick, break down, and turn into ulcers (open sores). Never try to cut calluses or corns yourself-this can lead to ulcers and infection. Let your health care provider cut your calluses. Also, do not try to remove calluses and corns with chemical agents. These products can burn your skin.

Foot Ulcers
Ulcers occur most often over the ball of the foot or on the bottom of the big toe. Ulcers on the sides of the foot are usually due to poorly fitting shoes. Remember, even though some Ulcers do not hurt, every ulcer should be seen by your health care provider right away. Neglecting Ulcers can result in infections, which in turn can lead to loss of a limb.
What your health care provider will do varies with your ulcer. Your health care provider should take X rays of your foot to make sure the bone is not infected. The health care provider will cut out any dead and infected tissue. You may need to go into the hospital for this. Also, the health care provider will culture the wound to find out what type of infection you have and which antibiotic will work best.

Keeping off your feet is very important. Walking on an ulcer can make it get larger and force the infection deeper into your foot. Your health care provider may put a special cast on your foot to protect it.

Good diabetes control is important. High blood sugar levels make it hard to fight infection.
If your ulcer is not healing and your circulation is poor, your health care provider may need to refer you to a vascular surgeon.

After the foot ulcer heals, you should still treat your foot carefully. Scar tissue under the healed wound will break down easily. You may need to wear special shoes after the ulcer is healed to protect this area and to prevent the ulcer from coming back.

Several things make some people more likely to get foot Ulcers. You are more prone to foot Ulcers if you are more than 40 years old, have had a foot ulcer before, have had diabetes-related changes in your eyes, or have kidney disease, nerve damage, or poor blood flow, especially to your feet.

Neuropathy
Although it can hurt, diabetic nerve damage (neuropathy) also can lessen your ability to feel pain, heat, and cold. Loss of feeling often means you may not feel a foot injury. You could have a tack or stone in your shoe and walk on it all day without knowing. You might not notice a foot injury until the skin breaks down and becomes infected.

Nerve damage can also lead to deformities of the feet and toes. Your toes may curl up. People with deformed feet and toes should not force them into regular shoes. Ask your health care provider about special therapeutic shoes.

Poor Circulation
Poor circulation (blood flow) can make your foot less able to fight infection and to heal. Diabetes causes blood vessels of the foot and leg to narrow and harden. You can control some of the things that cause poor blood flow. Don't smoke-smoking makes arteries harden faster. Also, follow your health care provider's advice for keeping your blood pressure and cholesterol under control.

If your feet are cold, you may be tempted to warm them. Unfortunately, if your feet cannot feel heat, it is easy for you to burn them with hot water, hot water bottles, or heating pads. The best way to help cold feet is to wear warm socks.

Exercise is good for poor circulation. It stimulates blood flow in the legs and feet. Walk in sturdy, good-fitting, comfortable shoes. Don't walk when you have open sores.

Some people feel pain in their calves when walking fast, up a hill, or on a hard surface. This condition is called intermittent claudication. Stopping to rest for a few moments should end the pain. If you have these symptoms, you must stop smoking. You should also see your health care provider to get started on a walking program. Some people can be helped with the medication Trental (pentoxifylline), as prescribed by their health care provider.

Amputation
People with diabetes are far more likely to have a foot or leg amputated than other people. The problem? Many people with diabetes have artery disease, which reduces blood flow to the feet. Also, many people with diabetes have nerve disease, which reduces sensation. Together, these problems make it easy to get ulcers and infections that may lead to amputation.

For these reasons, you should take good care of your feet and see your health care provider right away about foot problems. Always follow your health care provider's advice exactly when caring for ulcers or other foot problems.

One of the biggest threats to your feet is smoking. Smoking affects small blood vessels. It can cause decreased blood flow to the feet and make wounds heal slowly. A lot of people with diabetes who need amputations are smokers.

Often, your health care provider can prevent loss of a limb with an operation that improves blood flow in your feet.

Your Health Care Provider's Role
Because people with diabetes are more prone to foot problems, a podiatrist may be on your health care team.

Your health care provider should perform a complete foot exam at least annually-more often if you have foot problems.

Remember to take off your socks and shoes while you wait for your physical examination.

You should call or see your health care provider if you have cuts or breaks in the skinor have an ingrown nail. Also, tell your health care provider if the foot changes color, shape, or just feels different (for example, becomes less sensitive or hurts).

If you have corns or calluses, your health care provider can trim them for you. Your health care provider can also trim your toenails if you cannot do so safely.

Caring for Your Feet
There are many things you can do to keep your feet healthy.

Keep your blood sugar in control. Wash your feet every day. Dry them carefully, especially between the toes. Check your feet every day for sores, calluses, red spots, cuts, swelling, and blisters. If you cannot see the bottoms of your feet, use a mirror or ask someone for help.

Don't put your feet into hot water. Test water before putting your feet in it just as you would before bathing a baby. If your feet are cold, wear socks. Never use hot water bottles, heating pads, or electric blankets. You can burn your feet without realizing it. Don't cut off blood flow to your feet. Don't wear garters.

Do not use chemicals on corns, calluses, or warts. Over-the-counter products are often too strong for use by people with diabetes. They can burn your feet. Also, do not cut corns or calluses yourself. Cut your toenails straight across and file the edges. Do not rip off hangnails. Wear flat shoes that fit your feet. They should be comfortable when you buy them. Break in your new shoes slowly. If you have lost feeling in your feet, ask your health care provider for advice on proper shoes.

Consider wearing comfortable walking shoes every day.

Check inside your shoes before wearing them. Make sure there are no pebbles, nails, or other sharp objects in them and that the shoe itself is not rough and the lining is not torn.

Choose socks carefully. They should not have seams or other bumpy areas. Do not wear mended socks. Pull your socks on gently to prevent ripping a toenail. Choose padded athletic socks to protect your feet and make walking more comfortable. Never walk barefoot. You could burn or cut your feet and not notice it. Keep slippers by your bed to use when you get up at night.

Don't smoke.

See your health care provider at the first sign of infection or inflammation.
ON DIABETES
By Tamara Fishman, DPM
Many people with diabetes develop foot problems. What is diabetes? Diabetes is a condition in which either your pancreas does not produce enough insulin or it produces sufficient insulin but the cells of your body are unable to use the insulin properly. In the first case, your body does not have enough insulin to change the foods you eat into energy it needs to function normally. In the second case, enough insulin is available however the cells in your body are unable to use it to change the food you eat into energy. How does your body produce Insulin? To begin with, Insulin is produced by a gland called the pancreas. Insulin production makes it possible for the cells of your body to change food into energy or to store it for future uses. In order for glucose to be used by your body cells for energy insulin must be present in your blood stream. Insulin is a hormone that enters your blood stream that assists your cells in using glucose for energy for future use. Without insulin your body is unable to use the food you eat to sustain itself and therefore function in a normal manner. The likelihood of foot problems, resulting in infection and amputation are increased in the diabetic patient. The development of potential foot problems may be decreased with proper foot care. The two most prevalent foot problems are neuropathy and poor circulation. Neuropathy is a loss or lessening in your ability to feel in your feet. Poor circulation is common in people who have had diabetes for a long period of time. Cramping in your legs while walking is a early symptom that you may have poor circulation. Another symptoms is the slow or delayed healing of a cut or a scratch.

Things to Never do:

• never soak your feet.
• never apply heat of any type to your feet.
• never cut your toenails, see your podiatrist.
• never go barefoot, you run the risk of injury.
• never assume that your sensation or circulation in your feet is normal
• never use any over the counter medications without consulting your podiatrist first.
• never perform any bathroom surgery for example: cutting of corns or callouses with a razor or knife.
• never keep your feet too moist or too dry.
• never wear shoes that do not fit-this can cause injury to your skin.
• never allow corns or callouses go untreated-seek professional care by your podiatrist.
• visually inspect your feet on a daily basis.